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EUGENE R. VISCUSI, M.D., is Associate Professor of Anesthesiology, Director, Acute Pain Management, Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA. Address correspondence to Dr. Viscusi at Thomas Jefferson University Hospital, Department of Anesthesiology, 111 S. 11th Street, Suite G8490, Philadelphia, PA 19107 (eugene.viscusi{at}jefferson.edu).

Purpose. The advantages and disadvantages of intravenous patient-controlled analgesia (i.v. PCA) and epidural analgesia are discussed. New approaches to the management of patients with acute post-operative pain are described. The results of controlled clinical trials with these modalities are presented. Summary. Intravenous patient-controlled analgesia, while effective, is a burdensome technology requiring approximately 125 steps and at least 6 staff members. Furthermore, medication and pump programming errors may lead to patient injury. Epidural analgesia via catheter has a high reported failure rate, causing analgesic gaps and requiring a high level of staff intervention. In a clinical trial involving hip arthroplasty, extended-release epidural morphine demonstrated a 48-hour duration of action with a marked reduction in need for supplemental analgesia. The fentanyl Iontophoretic Transdermal System has demonstrated therapeutic equivalence with morphine intravenous patient-controlled analgesia and similar safety. Selective opioid antagonists are under development that may selectively block gastrointestinal opioid receptors while preserving analgesia. Conclusion. Recently approved agents and those in development may address a variety of unmet needs in the management of patients with post-operative pain. Index terms: Analgesics and antipyretics; Drug administration routes; Drug comparisons; Duration of action; Errors, medication; Fentanyl; Iontophoresis; Morphine; Opiate antagonists; Opiates; Pain; Patient-controlled analgesia; Surgery; Sustained-action medications; Technology; Toxicity